研究目的：關於亞洲國家的兒童虐待流行病學相關研究仍然闕如。本研究目的欲探討兒童虐待住院發生率趨勢，進一步分析年齡別、性別發生率趨勢。並釐清發生率趨勢改變是否是因為兒虐相關編碼使用改變而造成。此外，欲瞭解兒虐個案的住院型態。
研究材料與方法：本研究使用台灣1996年到2007年全民健保資料庫的住院醫療費用清單明細檔來進行分析。兒虐住院個案使用國際疾病分類臨床修正第九版(ICD-9-CM )來定義。凡住院申報資料的主次診斷中有包含傷害編碼 “兒童虐待症候群(995.5X)”或傷害外因編碼有 “他殺及被他人故意傷害(E960-E969)”的0-12歲個案，即被定義為兒虐個案。兒虐發生率根據波以松分佈計算95% CI，並使用波以松迴歸分析(Poisson regression)來檢定年齡別、性別發生率趨勢有無達顯著變化。發生率趨勢與編碼使用部分，將腦傷住院嬰兒中有硬腦膜下血腫(852.2, 852.3)及視網膜出血(362.81)診斷的定義為高度疑似虐待性腦傷，觀察診斷與外因編碼的使用分佈，以發生率及比例呈現，比較是否隨著年代而有差異。兒虐個案住院型態，使用數線圖記錄住院次數6次以上的個案之住院時間與診斷類型。之後透過病例對照研究，比較兒虐住院個案與非故意事故住院個案及全病因住院個案的住院次數差異。
結果：在1996到2007年間，總共有1726筆0–12歲兒虐住院事件。兒虐住院平均年發生率為嬰兒每十萬人13.2，1–3歲兒童每十萬人3.5，4–6歲兒童每十萬人2.1，7–12歲兒童每十萬人3.3。兒虐住院發生率趨勢在不同年齡族群有所差異，在嬰兒族群上升最顯著，由1996-1997年的4.8/100,000增加到2006-2007年的25.4/100,000，差了5倍之多。而發生率趨勢增加的程度隨著年齡增加而減少，在7–12歲兒童族群發生率趨勢並沒有隨著時間改變。在兒虐住院個案中，僅使用兒虐傷害性質編碼的比例在嬰兒族群最高，且比例在1996–2001到2002–2007年間有升高的趨勢，主要是因為新的ICD-9-CM編碼995.55“嬰兒搖晃症候群”從2003年開始被廣泛使用。腦傷是兒虐住院個案中的主要傷害類型，在每一個年齡族群皆是。在因腦傷住院嬰兒中，硬腦膜下血腫與視網膜出血的發生率在1996到2007年間有稍微的增加。其中，有使用兒虐編碼的發生率隨年代顯著增加，而沒有使用兒虐編碼的發生率沒有變化。兒虐住院個案的總平均住院次數及傷害平均就醫次數，不管在哪個年齡層，都較全病因住院個案多。
結論：台灣兒虐住院發生率在不同年齡族群中有所差異。嬰兒族群在過去十年間有最高的兒虐住院發生率，且上升幅度最顯著。發生率的增加可能是因為1993年兒童福利法修法，以及2001年ICD-9-CM 改版之後，醫療人員在診斷兒虐個案的覺知、能力以及意願都有提升而造成。以嬰兒高度疑似虐待性腦傷來看診斷編碼變化，發現使用兒虐相關編碼，尤其是嬰兒搖晃症候群的情形有顯著上升的趨勢，反映了發生率的增加可能是因為診斷與編碼的改變而導致。
臨床意涵：醫師和護理人員應了解並記錄兒虐住院個案詳細和具體的訊息，提供編碼人員進行適當的出院診斷編碼，使兒虐住院資料能有效估計發生率。行政資料中的兒虐住院個案都應該包含傷害性質編碼(N-code)及外因編碼(E-code)來提供更完整的訊息。另外，兒虐住院個案較一般住院個案有較多的住院次數及傷害相關住院次數，醫護人員應該了解這些徵象，及早發現兒虐高危險族群，進行適當的預防或必要的轉介與治療。

Objectives: Little is known regarding the epidemiology of child maltreatment in Asian countries. This study aimed to examine the incidence of hospitalization due to child maltreatment in Taiwan. Then, we assessed whether the changes of diagnose and coding in child maltreatment induce the incidence trend change overtime. In addition, to investigate patterns of hospitalization due to child maltreatment compared to other children.
Methods: We used inpatient claims data of the National Health Insurance for the years 1996 through 2007 for estimation. Hospitalization with an ICD-9 code 995.5 or E960–E969 in the main or secondary discharge diagnosis in claims data was defined as hospitalization due to child maltreatment. Head injury related hospitalization in infants with an ICD-9 code 852.2, 852.3 (Subdural hematoma, SDH) or code 362.81 (Retinal hemorrhage, RH) was defined as highly suspected abusive head injury. The following incidence rates were calculated: SDH and RH with or without child maltreatment codes, with unintentional injury codes (E-codes E880-E949), and without E code. Poisson regression was used to examine the trends. Frequencies of hospital admissions for cases versus controls were calculated, and Student's t-test was used to estimate the difference of hospital admission frequency on the case and control groups.
Results: A total of 1,726 children aged 0–12 years with 1,780 hospitalizations due to child maltreatment were identified during1996–2007. The averaged annual incidence over 1996–2007 was 13.2/100,000 for infants, 3.5/100,000 for children aged 1–3 years, 2.1/100,000 for children aged 4–6 years and 3.3/100,000 for children aged 7–12 years. The incidence increased most among the infant group, from 4.8/100,000 in 1996-1997 to 25.4/100,000 in 2006-2007, a greater than five-fold increase. The extent of the increase in incidence decreased with age, and no change in incidence was noted among children aged 7–12 years. The use of the N-code (ICD-9-CM code 995.5) only was highest among the infant group and increased from 2003 to 2007, mainly due to the new use of ICD-9-CM code 995.55 for “shaken infant syndrome” since 2003. Head injury was the main type of injury in all age groups. Incidence rate of SDH and RH in infants increased slightly from 1996 to 2007 in Taiwan. The rate of SDH and RH with child maltreatment codes increased markedly over time, and no change in SDH and RH without child maltreatment codes.
Conclusions: The incidence of hospitalization due to child maltreatment in Taiwan differed by age group. Infants had the highest and the largest increase in incidence during the past decade. The increase might be due to improvement in awareness, competence and willingness to diagnose child maltreatment of medical staff in hospitals during the past decade after the revision of Child Welfare Law in 1993 and the use of the 2001 version of the ICD-9-CM in 2003.
Practice implications: Physicians and nursing staff should be aware of and provide the detailed and specific information needed for proper discharge diagnosis coding, from which valid estimation of the incidence of hospitalization due to child maltreatment can be made. Administrative data should include both the N-code and E-code for each case of child maltreatment hospitalization to provide more complete information. In addition, hospitalizations due to child maltreatment have greater frequency of admission and injury-related admission than non-abused children. Physicians and nursing staff need to improve understanding of this admission characteristic where we can earlier identify high-risk families to prevent child maltreatment.

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